Imm 5782 e

PROTECTED WHEN COMPLETED - B
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Page 1 of 2
Date of receipt stamp at post
APPLICATION TO
VOLUNTARILY RENOUNCE
PERMANENT RESIDENT STATUS Space reserved for
All individuals, regardless of age, must complete their own application form. applicant's photo
All parents or legal guardians must complete and sign application for
children under the age of 18.
Use an extra sheet of paper if you need more space to answer a question.
Print your name at the top of the sheet and indicate the question number.
UCI/Client ID (if known)

I want service in: English French
PART A - PERSONAL INFORMATION

1 Your full name (as it appears on your Record of Landing (IMM 1000) or Confirmation of Permanent Residence (IMM 5292 or IMM 5688) or Permanent Resident Card)
Family name Given name(s)
Other names (for example, maiden name, son/daughter of, other family name, other given name)
2 Your gender 3 Your date of birth 4 Your place of birth

(YYYY-MM-DD)
F M X Another Town/City State/Province Country
Female Male gender
5 Your marital status (choose one)
Single Married Widowed Divorced Separated Common-law partner
6 Date and place you became a permanent resident of Canada

Date (YYYY-MM-DD) City Province
7 The number on your Record of Landing, Confirmation of Permanent 8 Passport number Delivery date (YYYY-MM-DD) Expiry date (YYYY-MM-DD)
Residence or Permanent Resident Card
9
a) Do you have citizenship status in a country? ► Yes No
If yes, indicate of which country(ies):
b) Are you a permanent resident of another country? ► Yes No c) Which country(ies) can you return to?
If yes, indicate of which country(ies):
10 a) Your current residential address

Street number and street name
City/Town Province/State Country Postal Code District
If we need to reach you while we process your application

Your telephone no. (country code, area code and number) Your e-mail address (if available)
b) Your mailing address (if different from above)

City/Town Province/State Country Postal Code District
c). Address in Canada where you intend to stay during your visit
City/Town Province/Territory Country Postal Code
This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.
IMM 5782 (07-2021) E (DISPONIBLE EN FRANÇAIS - IMM 5782 F)

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Page 2 of 2
PART B - DECLARATION
I confirm that I would like to voluntarily renounce my permanent resident status.I understand that, if my application to renounce permanent resident status is approved:I will no longer
be entitled to enter or remain in Canada as a permanent resident;I will only be able to enter or remain in Canada if I meet all regular requirements for a temporary resident (visitor,
student or worker);If I do not meet the requirements of the Immigration and Refugee Protection Act as a temporary resident, I could be barred from entering Canada or removed from
Canada;Any applications for Canadian citizenship or to sponsor my family members that I may have previously submitted will be refused and I will not receive a refund of the
processing fees;I will no longer be entitled to the social services available to permanent residents. If necessary, I have verified with the government departments that provide social
services and benefits that I cannot receive them if I am no longer a permanent resident of Canada.I understand that it is not necessary to renounce my permanent resident status in
Canada to become a Canadian citizen.If this form is for a child under the age of 18, I certify that I am one of the child's parents or legal guardians and that all of the child's parents or
legal guardians have signed the form.I understand the above statements; I have asked for and obtained an explanation on every point that was not clear to me. I also understand that
the information I provide may be verified and I consent to this verification.I certify that the information given on this form and on any attached documents is correct, complete and
accurate and that it is a serious offence to provide false or misleading information and that the provision of false or misleading information may be grounds for my prosecution and
removal from Canada.
Date
Signature of applicant
(YYYY-MM-DD)
Signature of parent or guardian - 1 Date

(if applicant is under the age of 18) (YYYY-MM-DD)
Name of parent or guardian
Note: In the event that the applicant named on this form has more than two guardians, the application must be accompanied by a signed and dated solemn
declaration indicating that all guardians understand and consent to the above conditions.
Signature of parent or guardian - 2 Date

(if applicant is under the age of 18) (YYYY-MM-DD)
Name of parent or guardian
Personal information provided on this form is collected by Immigration, Refugees, and Citizenship Canada (IRCC) under the authority of the Immigration and
Refugee Protection Act (IRPA). The personal information may be used for the purpose of processing an application. The personal information provided may
be disclosed to other federal government institutions, law enforcement bodies, provincial/territorial governments and foreign governments for the purpose of
validating identity, eligibility and admissibility.
Personal information may be used for other purposes including research, statistics, program and policy evaluation, internal audit, compliance, risk
management, strategy development and reporting, and subsequent program eligibility.
Failure to complete the form in full may result in a delay or the application not being processed. The Privacy Act gives individuals the right of access to,
protection, and correction of their personal information. If you are not satisfied with the manner in which IRCC handles your personal information, you may
exercise your right to file a complaint to the Office of the Privacy Commissioner of Canada. The collection, use, disclosure and retention of your personal
information is further described in IRCC's Personal Information Bank - IRCC PPU 068.
IMM 5782 (07-2021) E

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PROTECTED WHEN COMPLETED - B

Save Reset Form Print Form

Date of receipt stamp at post

UCI/Client ID (if known)

PART A - PERSONAL INFORMATION

2 Your gender 3 Your date of birth 4 Your place of birth

5 Your marital status (choose one)

Single Married Widowed Divorced Separated Common-law partner

6 Date and place you became a permanent resident of Canada

If yes, indicate of which country(ies):

10 a) Your current residential address

City/Town Province/State Country Postal Code District

If we need to reach you while we process your application

b) Your mailing address (if different from above)

City/Town Province/State Country Postal Code District

City/Town Province/Territory Country Postal Code

IMM 5782 (07-2021) E (DISPONIBLE EN FRANÇAIS - IMM 5782 F)

Signature of parent or guardian - 1 Date

Name of parent or guardian

Signature of parent or guardian - 2 Date

Name of parent or guardian

IMM 5782 (07-2021) E

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